Claims Payment Integrity Specialist, Health Plan

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.

Work Shift:

8 Hours - Day Shifts (United States of America)

Scheduled Weekly Hours:

40

Compensation:

Starting Rate: $21.50 - $34.50

Union Position:

No

Department Details

Summary

The Claims Payment Integrity Specialist is responsible for identifying, preventing, and recovering improper claim payments across all lines of business, including Medicare, Medicaid, on- and off Exchange, large group, small group, and TPA populations. This role plays a critical part in protecting plan assets by ensuring claims are paid accurately, compliantly, and in accordance with correct coding, contractual arrangements, regulatory requirements, and internal policies.

The specialist performs post payment audits, supports pre payment integrity initiatives, collaborates with internal and external partners, reports analytics/savings on payment integrity initiatives and contributes to continuous improvement of payment integrity strategies.

Job Description

Conducts pre or post payment claim reviews to identify overpayments, underpayments, duplicate payments, coding errors, and contractual discrepancies across all lines of business. Analyze claims using data analytics, reporting tools, and audit methodologies to detect trends, anomalies, and potential payment risks. Leads implementation of new initiatives to address incorrect payment trends or new claim editing solutions. Validate claims compliance with CMS, state Medicaid agencies, ACA, ERISA, and applicable regulatory requirements. Applies correct interpretation of benefits, provider contracts, fee schedules, reimbursement methodologies, and medical policies to payment integrity functions. Initiates recovery actions for identified overpayments, including coordination with providers, recovery vendors, or internal adjustment processes.

Prepares clear, accurate, and compliant written communications detailing audit findings and recovery rationales. Supports appeals, disputes, and provider inquiries related to payment integrity findings and functions. Partners with Claims Operations, Provider Relations, Compliance, Legal, Configuration, and Finance to resolve root causes of payment errors. Provides feedback and recommendations to improve claims configuration, policies, and workflows. Supports implementation of corrective actions and preventive controls to reduce future errors. Works closely with leadership team to gain deep understanding of business needs and provide recommendations as well as identify, analyze and develop strategies to maximize medical cost savings, administrative savings and minimize over and underpayment errors resulting from internal adjudication errors and provider billing practices. Maintains a detailed documentation of audit activities, findings, and outcomes. Contributes to reporting on payment integrity performance, recoveries, and identified risk areas. Participates in special projects, regulatory audits, and program integrity initiatives as assigned.

Qualifications

Associate's degree in Healthcare Administration, Business, Finance or a related field, required. Bachelor’s degree preferred. Will consider equivalent years of relevant work experience or combination of higher education and relevant experience in lieu of degree completion.

Two (2) years of experience in claims, payment integrity, audit, program integrity, or healthcare operations required. Experience working with multiple lines of business (Medicare, Medicaid, Commercial, Exchange, and/or TPA) required. Proficiency with claims systems and standard Microsoft Office tools (Excel, Word, Outlook) required.

Experience with claims data analytics or recovery vendor management preferred. Knowledge of CMS and state Medicaid program integrity expectations preferred.

Strong understanding of healthcare claims processing, reimbursement methodologies, and benefit structures. Working knowledge of Medicare, Medicaid, commercial, exchange, and TPA payment models. Ability to interpret provider contracts, fee schedules, and medical policies

Certified Professional Coder (CPC), Certified Payment Integrity Professional (CPIP), or similar certification preferred.

Sanford is an EEO/AA Employer M/F/Disability/Vet.

If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-949-5678 or send an email to talent@sanfordhealth.org.

The Sanford organization owns and manages multiple distinct brands, including Sanford Health, Marshfield Clinic, and Good Samaritan, as well as Lewis Drug, Sanford Health Equip, Solutions by Sanford, Great Shots, and Blue Rock Bar & Grill.

About Sanford Health

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Headquartered in Sioux Falls, South Dakota, the organization has 53,000 employees and serves over 2 million patients and nearly 425,000 health plan members across the upper Midwest including South Dakota, North Dakota, Minnesota, Wyoming, Iowa, Wisconsin and the Upper Peninsula of Michigan. The integrated nonprofit health system includes a network of 56 hospitals, 288 clinic locations, 147 senior care communities, 4,000 physicians and advanced practice providers and nearly 1,500 active clinical trials and studies. The organization’s transformational virtual care initiative brings patients closer to care with access to 78 specialties. Learn more about Sanford Health’s commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

About Good Samaritan

Good Samaritan, one of the nation’s largest nonprofit providers of senior care and services, is committed to transforming the aging experience through innovation, compassion and personalized care. As part of Sanford Health, an integrated nonprofit health system headquartered in Sioux Falls, South Dakota, Good Samaritan serves 10,000 seniors and offers access to a full continuum of care, including 94 rehabilitation and skilled nursing centers, 56 assisted living and memory care facilities, 44 independent living locations and 37 home health and hospice agencies. The senior care provider delivers services across the upper Midwest, with 70% of residents living in rural communities. Learn more about Good Samaritan’s mission and commitment to delivering high quality senior care in rural America at good-sam.com.